Doctor Name: | PANDU BONTHALA |
NPI Number: | 1861676520 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | M.D. |
License Number: | 19977 |
Business Practice Address: | 624 J Ave Nevada, IA - 502011922 |
Business Phone Number: | 5153822177 |
Business Fax Number: | 5153822178 |
Mailing Address: | 624 J Ave, Po Box 524 NEVADA |
State: | IA |
Postal Code: | 502011922 |
Phone Number: | 5153822177 |
Fax Number: | 5153822178 |
NPI Enumeration Date: | 12/18/2007 |
NPI Last Update Date: | 12/18/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 19977 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IA |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |